YOU GUYS GOOD with 3rd Year H&P's- Whadya think???

[einey]

How competent are you supposed to be at the end of the 3rd year internal medicine rotation? With respect to H&P's specifically the assesment and plan. My resident says most 3rd and 4 years A/P really suck. Can't always come up with a good plan or TX. Are you guys sucking at this or are you really good, honestly?

What about presentations in IM- People on my team stumble on them, not sure how perfect they need to be at this point.

Do all of you guys get pimped on DDX's and TX's alot. Just not sure if I'm getting the training I need or if most people are rudimentary on their H&P's A/P at this point during the 3 year?

I see the patient, write a template H&P that just gets stuck in a medical student file, don't really follow up labs cause the intern and residents do that-I don't know is my training in IM lacking?

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[SLUser11]

How competent are you supposed to be at the end of the 3rd year internal medicine rotation? With respect to H&P's specifically the assesment and plan. My resident says most 3rd and 4 years A/P really suck. Can't always come up with a good plan or TX. Are you guys sucking at this or are you really good, honestly?

What about presentations in IM- People on my team stumble on them, not sure how perfect they need to be at this point.

Do all of you guys get pimped on DDX's and TX's alot. Just not sure if I'm getting the training I need or if most people are rudimentary on their H&P's A/P at this point during the 3 year?

I see the patient, write a template H&P that just gets stuck in a medical student file, don't really follow up labs cause the intern and residents do that-I don't know is my training in IM lacking?

Well, if it helps, every med student on my internal medicine team peed in their pants on rounds....so I did too. I mean, none of the residents TOLD me I had to go to the bathroom and unzip my pants to do that!


Seriously, I believe that both possible answers are true:

1) Depending on when you have IM, your DDxs and treatment plans might be shallow....I remember plenty of people using previous notes in the chart as a template for my own....wait....I mean THEIR own....note during the first few days before they really knew the ropes. As time goes on, you learn more, and you learn how to think more effectively, and your notes and presentations get better. By the end, you shouldn't be an EXPERT, but you shouldn't be stumbling too much.

As for the not following up labs thing "cause my intern already did it," start doing it....that's just stupid.

2) At the same time, SOME interns and residents, especially in the cerebral specialties (IM, neuro, etc), are too critical of med students, constantly remarking on how crappy their DDxs, etc. are, in what I believe to be overcompensation. "I'm so smart and they're so dumb." Don't take it all to heart.

 

[Dr JPH]

The first thing I can say is dont mimick your H&P after any attendings or residents...you need to find your own style. The problem is each intern, resident and attending has a way that they like to see students do something so often times no matter what you write there will be something that SOMEONE doesnt like.

Dont get discouraged. I think it just gets to a point where writing these things becomes second nature.

You will have plenty of practice before you graduate. If you end up taking call and have to do ER admissions all night you will quickly get the hang of it.

I think I wrote more H&Ps on my one week of night float than in the entirety of my 3rd year.

 

[tiredmom]

I feel like mine have gotten better over the year. Our school gives our a template that they want us to follow, more or less. I've definately gotten much faster at it, too. I think the differential depth really depends on who you are working with. At the VA - we spent a lot of time... the differential might take up 1 page typed on the EMR. At the military hospital... maybe 2-4 sentences per problem - any more than that and the intern would edit it down.

 

[Wednesday]

Well first remember that you're SUPPOSED to be bad at this stuff--that's why you're learning it. I mean, the residents SHOULD be better than you are. As for A/P, that's something we're told to always try to do because if you're forced to put something down on paper you have to force yourself to think through it and make a decision. They're not necessarily supposed to be correct! That comes with time. In fact, putting down an plan and discussing it with your team is a great way to learn. We're told that fourth-year is when you really start figuring out how to do a great Plan and I found that this was pretty much on target. It's when things really start to come together and instead of worrying about the questions you forgot to ask, you can really look into the future and figure out what needs to be done and in what order to move the process along. I think that by the time you're done with third year, you should be pretty good at differentials. If not, the residents/attendings aren't spending enough time with you (or you're not practicing enough!)

As for learning to write a good note, I also used former notes as templates--take the good things, disregard the things you don't think work as well. It's not that your notes will then all be identical to that person's style. Again, after a while your notes DO take on their own style, but at first you have NO style, you gotta start from something.

You should always check labs, even if other people do it too. You're learning to take care of your patients. The residents should be more efficient at this point and they need the info too, but how will you learn to be like them if you don't start at some point? You may be suprised how happy they will be (and it sounds like surprised) if you bust out with some abnormal value before they've had a chance to check.

Practice presenting. Ask for feedback. You gotta take hold of your own education.

 

[jennyboo]

How competent are you supposed to be at the end of the 3rd year internal medicine rotation? With respect to H&P's specifically the assesment and plan. My resident says most 3rd and 4 years A/P really suck. Can't always come up with a good plan or TX. Are you guys sucking at this or are you really good, honestly?

I see the patient, write a template H&P that just gets stuck in a medical student file, don't really follow up labs cause the intern and residents do that-I don't know is my training in IM lacking?

I agree that your notes are EXPECTED to be not that great, so don't hold unrealistic expectations for knowing how to do everything -- you're not expected to know how to do anything.

Do keep writing and filling stuff into your notes. Do include a differential (you won't be great at forming them at first, but you will get better at that the more you do).

Do follow up labs and include them in your note.

 

[Dr JPH]

I think another thing that really helped me was an ICU month.

I was assigned 3 patients, 2 of which I had nearly the entire time so part of my brain was just copying while the other part was storing the format. Does that make sense?

With the ICU notes you pretty much cover each system, its problems and a differential. Certainly a different format than a standard H&P, but it gets you into the mindset of "system - findings - problem - treatment"

 

[Doc Oc]

Photocopy your notes and in the first week (preferably the first day) of your rotation, have someone on your team go over your format with you and really rip it apart. Tell them you want them to rip it apart. Then go from there for that rotation, but rinse/repeat for the next rotation.

The "Rinse" part is important, because what you perfect on one rotation is wrong for your next one. A prime example would be writing an IM-type note on a surgery rotation. It does get a little spirit-crushing to constantly suck at something, perfect it, only to find out that again, once more, YOU SUCK! For me, having control over who tore me a new one and when was comforting. Better to ask for it and correct it then to find out via your evaluation because those who seemed to have no time to teach you apparently also had no time to inform you of your suckiness

 

[SLUser11]

Photocopy your notes and in the first week (preferably the first day) of your rotation, have someone on your team go over your format with you and really rip it apart. Tell them you want them to rip it apart. Then go from there for that rotation, but rinse/repeat for the next rotation.

The "Rinse" part is important, because what you perfect on one rotation is wrong for your next one. A prime example would be writing an IM-type note on a surgery rotation. It does get a little spirit-crushing to constantly suck at something, perfect it, only to find out that again, once more, YOU SUCK! For me, having control over who tore me a new one and when was comforting. Better to ask for it and correct it then to find out via your evaluation because those who seemed to have no time to teach you apparently also had no time to inform you of your suckiness

There was a lot of tearing, ripping, sucking, and crushing in that post....but at least there was rinsing too......

 

[THP]

2nd week of 3rd year here. I'm starting with surgery. Today I saw a complicated new patient in clinic and rather than presenting it to the resident, he told me to dictate it along with the assesment and plan (he did tell me the plan however). I have only ever written up 1 H and P and have never dictated anything before. It was awful, it took me like 30 min to do it. The residents all made fun of me for the rest of the afternoon b/c it took so long. Oh well. I think they at least respected the fact I tried.

In conclusion, mine suck a$$.

 

[Dr JPH]

Practice will get you there. No worries.

 

[bulldog]

on the wards, it's all about "name the differential dx" and 'what's the most common.."....on the shelf, they never ask any of that.

 

[Bobblehead]

How competent are you supposed to be at the end of the 3rd year internal medicine rotation? With respect to H&P's specifically the assesment and plan. My resident says most 3rd and 4 years A/P really suck. Can't always come up with a good plan or TX. Are you guys sucking at this or are you really good, honestly?

That's because there are vast differences between a "complete H&P" ala classroom ideal, what a med student actually writes on the wards, what an intern/resident writes, what an academic attending writes and what goes on out in the community.

You can put every last shred of information you could milk from Uptodate in the A/P listing dozens of DDx and the only person that'll ever read that note will be the person assigned to grade your H&P or a lawyer running a distant second. That's usually how you start. No one on a clinical service will bother reading 95% of it ever. So to them it's useless. To you it may be useful because you'll get a good grade for it from someone (key word being "may"). Then you quickly end up paring that down to something more functional where you've given it some thought, generated as many things as you want to evaluate as your DDx (common #1, common #2, bad to miss #1, etc.). In other words unless you're ordering something to evaluate said condition it won't make it onto that list. Then when you get to be in a hurry this shortens dramatically depending on how many you're writing and how much time you get to do it in.

 

[Sammich81]

2nd week of 3rd year here. I'm starting with surgery. Today I saw a complicated new patient in clinic and rather than presenting it to the resident, he told me to dictate it along with the assesment and plan (he did tell me the plan however). I have only ever written up 1 H and P and have never dictated anything before. It was awful, it took me like 30 min to do it. The residents all made fun of me for the rest of the afternoon b/c it took so long. Oh well. I think they at least respected the fact I tried.

In conclusion, mine suck a$$.

They do respect that you tried, dude. Surgery is a hell of a way to be broken into third year. I started on peds and it was great--they coddled me like one of the patients! Your H&Ps will start sucking less. However, on surgery, thoroughness for the sake of thoroughness (ie listing a million things on the ddx just to look smart like they make you do on medicine) is less valued. For example, one student who rotated on gen surg w/me consistently commented on the conjunctiva on physical exam every day--EVERY DAY!-- after our chief made fun of her several times until finally he said, "I don't ever want to hear about conjunctiva unless they're hemorrhaging." Like someone else already posted, you have to tailor what you're doing to that service.

As for medicine/ICU patients, I'm on the MICU right now. It breaks my brain into itty bitty pieces just trying to keep track of my two patients' problems. I do my notes like this: one liner summarizing the patient, 24 hour events, vitals, exam, abnormal lab values/imaging results/consults following along. And then for my A/P I do a problem list, in order of which problems are the most likely to kill them soon. So for example say you have a pt w/cirrhosis who came in with emesis, a big bad pneumonia, volume depleted, oh by the way has kicked himself into renal failure and has altered mental status--it would go:
1. Sepsis/pneumonia: community-acquired vs apiration pneumonia vs aspiration pneumonitis. Begin empiric tx with antibiotic X (in this case Zosyn and Cipro); obtained CXR, blood and sputum cultures.
2. Respiratory failure: intubated with ABG of_____. Will wean FiO2 preferentially as tolerated.
3. Volume status: aggressive vol resuscitation with normal saline/lactated ringer's.
4. Renal failure: Cr is ___ up from baseline of ___ last month. Will monitor urine output, obtain UA.

And so on. Then at the end you go through it by organ system (CNS, CV, pulm etc) to make sure you haven't missed anything. I also note any pending labs that are important beyond the usual CBC, BMP and also major trends in values: ie is bili trending up? Is the creatinine coming down? Is the patient getting anemic and if so do we have a source for bleeding?

Doing a prioritized problem list shows the team that you get the big picture on your patient, or at least that you're trying to.

 

[randomedstudent]

How competent are you supposed to be at the end of the 3rd year internal medicine rotation? With respect to H&P's specifically the assesment and plan. My resident says most 3rd and 4 years A/P really suck. Can't always come up with a good plan or TX. Are you guys sucking at this or are you really good, honestly?

What about presentations in IM- People on my team stumble on them, not sure how perfect they need to be at this point.

Do all of you guys get pimped on DDX's and TX's alot. Just not sure if I'm getting the training I need or if most people are rudimentary on their H&P's A/P at this point during the 3 year?

I see the patient, write a template H&P that just gets stuck in a medical student file, don't really follow up labs cause the intern and residents do that-I don't know is my training in IM lacking?

I am nearing the end of 3rd year and personally I think I still suck at H&Ps. It's difficult for me b/c each rotation (and each team within a rotation for that matter) want them differently so I feel like I can't really get in a groove with them. A/P's are esp. hard for me, I don't know why, I just always seem to forget things and then remember them like 3 hours later.

 

[ImaMedStud]

How competent are you supposed to be at the end of the 3rd year internal medicine rotation? With respect to H&P's specifically the assesment and plan. My resident says most 3rd and 4 years A/P really suck. Can't always come up with a good plan or TX. Are you guys sucking at this or are you really good, honestly?

What about presentations in IM- People on my team stumble on them, not sure how perfect they need to be at this point.

Do all of you guys get pimped on DDX's and TX's alot. Just not sure if I'm getting the training I need or if most people are rudimentary on their H&P's A/P at this point during the 3 year?

I see the patient, write a template H&P that just gets stuck in a medical student file, don't really follow up labs cause the intern and residents do that-I don't know is my training in IM lacking?

No worries, ending the third yr on IM at VA and since day one felt like the questionable admission. Seriously, my first clerkship was peds and I didn't feel as bad as I do now... also wondering how I honored Surgery only to get the daily smackdown on my admit notes, progress notes and presentations. In short, every attending is anal in thier own way, you just got to roll with the punches, break your preconceprions and work with what you've got, even if that means feeling like a dumba#s everyday. Try to keep up with the intern and residents re. the pts you follow in spite of the fact your noted don't count and according to the AAMC, you're not responsible for pt care. Being on the wards is about paying your dues, not about the shelf or even learning the stuff that could actually be useful or save you a lot of grief. Following a pt is the only connection between the vast amt of book crap and real-world crap we'll get with the short white coat on, so I'd be looking up thoe labs.